A comparison of the policy and institutional environment relevant to community-based primary health care in Ontario, Quebec and New Zealand

摘要

Introduction : Community-based primary health care (CBPHC) describes a model of service provision that is oriented to the population health needs and wants of service users and communities, and has particular relevance to supporting the growing proportion of the population with multiple chronic conditions. Internationally, aspirations for CBPHC have stimulated local initiatives and influenced the design of policy solutions. However, the ways in which these ideas and influences find their way into policy and practice is strongly mediated by policy settings and institutional path dependencies. This paper compares key features of the policy and institutional environments relevant to community-based primary health care in Ontario, Quebec and New Zealand. Theory/Methods : Drawing on existing literature and our collective expertise, we sought to identify the key organisational landscapes, service models, integrating mechanisms, and relevant policy developments within each jurisdiction. From these descriptions we develop a comparative analysis of enablers and facilitators. Results : Our analysis suggests that Ontario has the most significant institutional barriers to organisational integration and the fewest available policy levers, whilst New Zealand has the most conducive organisational landscape and strongest policy levers. Quebec has significant capacity for reform the structure of the health system, but reforms to date these have not incorporated primary health care. Conclusions: (comprising key findings) Our analysis suggests that two key conditions include the integration of relevant health and social sector organisations, and the range of policy levers available and used by governments. On both dimensions, the New Zealand environment appears to offer the largest scope, with Ontario’s environment significantly less conducive, with Quebec situated in between. Nevertheless, in each case there remain important institutional barriers to implementation of policies that promote CBPHC. Lessons Learned : Although New Zealand has more powerful policy levers, the effectiveness of levers is largely dependent on implementation strategies. Here the differences between New Zealand, Quebec and Ontario are less marked. Limitations : This research constitutes a preliminary, high-level understanding of the complex policy environments of three comparable policy and institutional environments. However, the degree to which the factors identified are key facilitators and inhibitors of CBPHC requires empirical investigation such that other significant policy and institutional constraints and enablers can be identified. Suggestions for Future Research : This research serves to inform the broader iCoach research collaboration, which investigates a range of specific local CBPHC initiatives and embedded practices that focus on older adults with complex conditions. Moving forward our research will focus on the analysis of key stakeholder interviews conducted within Ontario, Quebec and New Zealand to identify key institutional and policy settings that may enable and constrain the implementation and diffusion of these initiatives.